Provider Demographics
NPI:1013269828
Name:DAVILA-WITTROCK, IRENE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:
Last Name:DAVILA-WITTROCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MRS
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:DAVILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33330 8TH AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-945-2086
Mailing Address - Fax:253-945-2177
Practice Address - Street 1:33330 8TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6325
Practice Address - Country:US
Practice Address - Phone:253-945-2086
Practice Address - Fax:253-945-2177
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002029225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist